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A detailed nursing care plan for a patient diagnosed with acute appendicitis. It outlines the patient's medical history, identified nursing problems, and the interventions implemented to address them. The plan includes pre-operative and post-operative objectives, nursing diagnoses, interventions, and evaluations. It provides a comprehensive overview of the nursing process applied to a specific case, demonstrating the application of nursing knowledge and skills in practice.
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Although the origins of nursing predate the mid-19th century, the history of professional nursing traditionally begins with Florence Nightingale. Nightingale, the well-educated daughter of wealthy British parents, defied social conventions and decided to become a nurse. The nursing of strangers, either in hospitals or in their homes, was not then seen as a respectable career for well-bred ladies, who, if they wished to nurse, were expected to do so only for sick family and intimate friends. In a radical departure from these views, Nightingale believed that well-educated women, using scientific principles and informed education about healthy lifestyles, could dramatically improve the care of sick patients. Moreover, she believed that nursing provided an ideal independent calling full of intellectual and social freedom for women, who at that time had few other career options. In 1854 Nightingale had the opportunity to test her beliefs during Britain’s Crimean War. Newspaper stories reporting that sick and wounded Russian soldiers nursed by religious orders fared much better than British soldiers inflamed public opinion. In response, the British government asked Nightingale to take a small group of nurses to the military hospital at Scutari (modern-day Üsküdar, Turk.). Within days of their arrival, Nightingale and her nurses had reorganized the barracks hospital in accordance with 19th-century science: walls were scrubbed for sanitation, windows opened for ventilation, nourishing food prepared and served, and medications and treatments efficiently administered. Within weeks death rates plummeted, and soldiers were no longer sickened by infectious diseases arising from poor sanitary conditions. Within months a grateful public knew of the work of the “Lady with the Lamp,” who made nightly rounds comforting the sick and wounded. By the end of the 19th century, the entire Western world shared Nightingale’s belief in the worth of educated nurses.
IV patient and family from the time of admission till when patient is finally discharged to go home, as well as follow-ups or home visits for continuity of care. The study also involves the nursing process which involves assessment of patient/ family, planning of care to be rendered, implementing the plan and evaluating care rendered to patient/ family. The study is carried out to enable the student nurse put into practice the knowledge and skills acquired from the three year training period in school to ascertain how best the theoretical knowledge would be used to nurse patients who will come under his or her care in the near future. The study also forms part of the requirements of the Nursing and Midwifery Council of Ghana for the award of licence in General Nursing. In this study, initials of patient are used for confidentiality.
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My first and ultimate appreciation goes to the Almighty God for providing me with strength and knowledge for this project to materialize. It is my greatest pleasure to express my sincere gratitude to my supervisor for being my source of motivation during this study. Special thanks go to Mr. M.S, the subject of the study and his family for the smooth interactions and co-operation. I am much grateful to all the staff of Holy Family Nursing and midwifery Training College- Berekum, most especially my principal and my supervisor for their tireless efforts, sleepless nights, guidance and corrections for this successful script. I am also grateful to the medical doctors and the staff nurses of the Male Surgical Ward of Sunyani Regional Hospital. Further, I would like to extend my appreciation to my wonderful parents and senior brother, for their unending emotional, moral, spiritual, and financial support throughout the period of the study. Lastly, I am very grateful to all the publishers and authors whose books I used during the course of my Study. May God bless them.
VII Objectives were set and nursing orders implemented to resolved them. Nursing interventions such as reassurance, observing patient’s wound for discharge, educating patient on his disease condition, assessing appropriate pain severity using pain scale and administering of prescribed drugs were carried out successfully. All goals were fully met and no amendment was made. Patient’s condition improved considerably and was discharged on 2 8 th^ August, 2023 and was to report on 5 th^ September, 2023 for review. Three home visits were carried out. First home visit was done when my patient was still on admission with the aim of knowing the patient’s residence and environment in which he resides and also to identify the predisposing factors to the condition. Second home visit was done after discharge to inspect the wound for drainage and to remind him on the review date. Patient came for review on 5 th September, 2023 where he was given Tab Amoxiclav 1g bdx5. Alternate stiches removal was done. The third home visit was to find out how patient was faring and to hand over patient to the public health nurse to ensure continuity of care. After interacting with them during the third home visit, I thanked patient and family for their cooperation throughout the study. This care study comprises of six chapters as follows: Chapter one deals with assessment of patient and family. This involves collection of data about the patient to identify his problems. Chapter two deals with analysis of data. Chapter three comprises the planning phase of the nursing process and has the tabulated plan of care for the stated nursing diagnoses spanning the objective criteria, nursing orders, intervention and evaluation.
VIII Chapter four tackles the actual implementation of the care plan giving summary descriptions of activities which were undertaken from the moment of first contact with the patient at the time of admission to the ward till discharge and subsequent follow up with home visit. In chapter five, evaluation of nursing care given to the patient and family from encounter till termination of nurse-patient relationship is discussed. Chapter six focuses on the summary and conclusion of the care study report by reviewing thematic issues that arose in the care study from admission to last home visit after discharge.
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6.0 Introduction .................................................................................................................... 63 6.1 Summary of Care Rendered ........................................................................................... 63 BIBLIOGRAPHY .................................................................................................................. 69 SIGNATORIES .......................................................................... Error! Bookmark not defined.
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1.0 Introduction According to Hinkle and Cheever (2018) assessment is the systematic collection of data to determine the patient’s health status and any actual or potential health problems. The first phase of the nursing process is the assessment of the patient/family during the admission process. It entails collection of data from the patient/family through interviews, medical records, laboratory investigations and examinations. It covers the patient’s particulars, family medical/surgical history, family socio-economic history, patient’s developmental history, patient’s obstetric history, patient’s lifestyle and hobbies, patient’s past medical/surgical history and the present medical/surgical history of the patient, literature review and validation of data. It continues from the day of admission and ends after termination of care. The patient/family’s problems were identified and the appropriate nursing interventions rendered based on the information gathered. 1.1 Patient’s Particulars Patient particulars are defined as the biographical state of an individual within a particular geographical area at a particular time. (Gulanick M. Myers, J.L., 2019). Mr. M.S is the patient for the care study. He is 27-year-old, born on 1st^ August, 1996 to Madam A. W. and Mr. M. K. at Sakogo in the Gambaga District. He is a steel bender. He attended Sakogo primary school from class 1 to class 6 but could not continue due to financial difficulties in the family. He hails from Sakogo but resides at Yawhima Shooting Range in the house numbered SY66/4. He is dark in complexion with a height of 1.65metres and weighs 76kg. He is not married. He is a Muslim. Miss H. M. his younger sister is her
2 next of kin who resides at Sakogo in the Damba District. He speaks Mamprusi and Twi. He has no physical deformity. 1.2 Family’s Medical/Surgical History Medical history is a narrative or record of past events and circumstances that are or may be relevant to a patient’s current state of health whiles surgical history is a history of surgical procedures that a particular person has had (Lutcher, 2019). The interaction with Mr. M.S. and family revealed that some of the men in their family are alcoholics, no known chronic, familial or genetic diseases such as epilepsy, hypertension, asthma, mental sub-normality or any other abnormality in their family. His grandparents were all hospitalized before their deaths but the various diagnosis was not known to them. They use over-the-counter drugs (OTCs) for minor sicknesses like headache, constipation, boils and fever but always seek medical attention at the Bono Regional Hospital, Sunyani when their conditions worsen. His elder sister underwent surgery to remove an unknown mass from his abdomen. None of their relatives except the aforementioned has undergone surgery of any kind for any reason. There is no known family allergy. 1.3 Family’s Socio-Economic History According to Webster (2020) it is the position of an individual on socio-economic scale that measures such factors as education, income and occupation. The family of Mr. M. S. is an extended one in which the family members relate well with one another. According to him, he receives emotional support from his elder brother. Most of the family members are subsistence farmers, so they earn less income from the surplus of food crops such as cassava and plantain they sell. According to them, their farms are small and they have not been able to calculate their annual income due to the subsistence farming they are
4 people. It describes a commitment in which personal sacrifices are made for another, whether it be another person, or if one chooses, a career or other type of cause or endeavor to which an individual elect to devote his or her life. Intimacy is achieved when an individual has developed the capacity for giving of oneself to another. This is learned when one has been the recipient of this type of giving within the family unit. Non-achievement results in withdrawal, social isolation, and aloneness. The individual is unable to form lasting, intimate relationships, often seeking intimacy through numerous superficial sexual contacts. No career is established; he or she may have a history of occupational changes (or may fear change and thus remain in an undesirable job situation). The task remains unresolved when love in the home has been deprived or distorted through the younger years (Murray et al, 2019). One fails to achieve the ability to give of the self without having been the recipient early on from primary caregivers. M.S. has almost achieved this developmental stage since he associates himself in social activities. He also behaves well towards the opposite sex, though he is not married but has a fiancée which they are moving on well. 1.5 Patient’s Lifestyle/Hobbies Life style is defined as the habits, attitudes, moral standards, economic level etc that together constitute the mode of living of an individual or group whiles hobby is an activity or interest pursued for pleasure or relaxation and not as a main occupation (Webster, 2020). According to Mr. M. S., he normally goes to bed at 9:00pm and wakes up around 4:30am, washes her face, brushes his teeth using pepsodent toothpaste and brush. At about 7:00am, he goes to his farm and returns home at about 4:00pm. He later watches television, takes his bath and goes to bed. He normally empties his bladder four (4) times a day and empties his bowel twice daily. He brushes his teeth before bed. On Friday, he goes to the mosque to pray to Allah. He likes eating rice with any kind of stew or soup. He usually sleeps/rests for an hour during the day and sleeps for about seven and half
5 (7^1 2 ) hours during the night. He usually has no problems with sleep but if he does, he takes some sedatives like valium (diazepam) to help him sleep. He has no known allergy. He loves playing football and engages himself in moderate exercises in the evenings. Apart from Friday, all holidays and “resting” days from farming are used to for fun time with friends. He attends wedding ceremonies, funeral celebrations, but has never embarked on an excursion before. He is a very good person to interact with, he is loving, open, fair, firm, disciplined, respectful and God fearing to mention a few. He dislikes frowning and likes healthy relationships. 1.6 Patient’s Past Medical/Surgical History Past medical and surgical history talks about the patient’s past experiences with illnesses, operations, injuries and treatment. (Webster, 2020) Mr. M. S. had no childhood diseases like whooping cough, measles or any other disease as he grew through adolescent to adulthood. He has no known allergy. He has never been admitted to the hospital before. He always relies on over-the-counter drugs (OTCs) like paracetamol, amoxicillin and flucloxacillin for minor ailments and diazepam when he has trouble sleeping. He has never been involved in any accident. He has not undergone any surgical procedure before. He relies on the NHIS to seek medical attention. Mr. M. S. does not go for medical check-ups. 1.7 Patient’s Present Medical/Surgical History Patient stated that he was faring well until 25th August, 2023 when he experienced mild abdominal pain particularly at the right iliac fossa region around 7:00am but did not pay much attention to it. According to Mr. M.S., the pain became severe and unbearable around 2:00pm in the afternoon and he was rushed to the Accident and Emergency Unit of Sunyani Regional
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8 I introduced myself again to Mr. M.S. as a final year nursing student of Holy Family Nursing and Midwifery Training College, Berekum who wants to care for him with the aid of other staffs and would like to take his for my care study. Nursing care was planned using the nursing process for patient and family. The purpose of the care study is that before one becomes a professional nurse the person needs to carry out a study on a patient in partial fulfillment for the award of diploma certificate. I reassured them of confidentiality based on the information provided and total comprehensive and holistic nursing care. His sister and brother was informed that, their stay in the hospital is temporal and will be discharged home if Mr. M. S’s condition subsides. I told him about a visit which would be made to his house whilst Mr. M.S. was still on admission and after discharge. I thanked him for his cooperation and also assured him that the information that will be given will be kept confidential. I chose to write on this condition (Acute Appendicitis) because I wanted to gain more insight about it.
1. 9 Patient’s Concept of Illness Patient believed that it is normal to fall sick irrespective of whoever you are. Upon interviewing the patient, he did not attribute his sickness to any spiritual factor but he strongly said that by the grace of Almighty God and with the quality care from the hospital staff, he will get better soon. 1.1 0 Literature Review On Appendicitis Definition According to Hinkle and Cheever (2018) appendicitis is an inflammation of the vermiform appendix, the appendix is a small, fingerlike pouch about 8cm (3inches) long attached to the caecum of the colon. Its usual location is the right iliac region, just below the ileocecal valve.
